Provider Demographics
NPI:1124656749
Name:PETITE, ALEXIS JADE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JADE
Last Name:PETITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:HINCKLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55037-3784
Mailing Address - Country:US
Mailing Address - Phone:320-405-8397
Mailing Address - Fax:
Practice Address - Street 1:114 5TH ST NE
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037-3784
Practice Address - Country:US
Practice Address - Phone:320-405-8397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer